Tuesday, March 07, 2017

How the New Health Care Bill Confirms the Asymmetry of the Parties

Matt Grossmann and I write a fair amount about health care in our book Asymmetric Politics because it's a political issue that represents a particularly effective example of our main thesis: that the Democratic Party is organized as a coalition of social groups while the Republican Party is controlled by an ideological movement. Now that the House Republican leadership has released its health care reform proposal—the long-promised plan to "repeal and replace" the Affordable Care Act—it is clearer than ever that the two parties are fundamentally different in character.

The Democratic Party is composed of a number of discrete social groups, each of which pressures party leaders to support and enact policies designed to ameliorate specific perceived problems faced by the group. For decades, Democratic constituencies have demanded that their party act to provide health care benefits to vulnerable populations—a goal that was addressed by the creation of Medicare and Medicaid in the 1960s, the Children's Health Insurance Program in the 1990s, and the Affordable Care Act in 2009–2010.

By and large, Democrats are less concerned about the mechanics by which a policy is implemented than they are about the real-world effects of that policy. For example, the Affordable Care Act did not reflect an overarching ideological vision for the nation's health care sector, but instead was designed to minimize disruption to the existing system (in order to increase its chances of passage through Congress) while extending insurance and other benefits to a greater proportion of the public.

Democratic leaders worked for years to negotiate compromises with a range of powerful stake-holders in order to develop a bill that had a chance of passing into law, in order to achieve at least a degree of policy-making success. Pragmatism, not purity, is the dominant style of governing among Democratic politicians, and even liberals within the party who preferred a single-payer system to the relatively inelegant Obamacare apparatus supported the legislation as a partial victory and the best realistic option available to address the practical concerns of their constituents—rather than torpedoing the entire effort in the name of ideological principle.

The Republicans, as one might observe these days, work differently. The bill that Paul Ryan and his congressional allies have released is not the product of extensive deliberation among interest groups, health care providers, or policy experts. Nor is it designed to achieve a particular outcome with respect to the quantity or quality of coverage available to the public. Instead, the legislation is primarily motivated by the goal of reducing federal involvement in the provision of health care to the extent that is politically possible, repealing the individual mandate (deemed unconstitutionally coercive by contemporary conservative ideology) and imposing significant cuts to the federal Medicaid program.

Much has been made of the fact that the House plans to begin legislative action on the Ryan bill without a score from the Congressional Budget Office estimating its total cost and projected effect on the number of Americans with health insurance. This decision supposedly reflects the desperation felt by Republican leaders to push the bill through the committee process as quickly as possible, as well as an expectation that the CBO's numbers, when they come, will indicate that the bill would cause a sizable rise in the proportion of uninsured citizens.

But the lack of interest in the CBO score also demonstrates what the central purpose of the bill actually is. For Democrats, the point of enacting the ACA was to increase the number of Americans who had health insurance, and any legislation that failed to significantly reduce the ranks of the uninsured was, by that standard, not worth passing. Validation from outside experts that the ACA would indeed fulfill the goal of coverage expansion was thus necessary in order to maintain party support.

Republicans, in contrast, are much more indifferent to the question of what effect their own replacement bill will have on the number of insured Americans. An unfavorable CBO score will be politically damaging, to be sure, but is less likely to influence their evaluation of the inherent merits of the legislation. (Reducing the size of the Medicaid program is fully consistent with the ideological objectives of the party—a feature, not a bug.)

Some liberals have responded to our characterization of the Republican Party as fundamentally ideological by arguing that Republicans don't really adhere to a coherent value system but rather merely do the bidding of wealthy citizens and big corporations. But the Ryan bill can't really be explained on that basis. The rich do benefit by receiving a large tax cut, but if Republicans only cared about that issue they would have chosen to pursue a politically easier path of merely cutting taxes on the wealthy while leaving health care alone. Similarly, it's far from clear that insurance companies are getting much out of the Ryan bill; in fact, the repeal of the individual mandate might well lead to a market "death spiral" that would raise insurance premiums and reduce the number of customers.

But perhaps the strongest current evidence in favor of our argument about the differences between the parties is the unique power of ideologically purist activists and pressure groups within the GOP. In what is surely the biggest political news of the day, one conservative organization after another—the Club for Growth, Heritage Action, FreedomWorks, the Koch-funded Americans for Prosperity—has announced its opposition to the Ryan bill, claiming that it doesn't go far enough in repealing the ACA and reducing the government's role in the provision of health care.

Of course, these groups' criticisms only make it more likely that Ryan's reform bill will fail and the ACA will remain in place, squandering a potential opportunity to move federal health care policy further to the ideological right. As we argue in Asymmetric Politics, it is time to devote more serious attention to the fact that the increasing power of the conservative movement and growing electoral success of the Republican Party over the past few decades have not yet come close to achieving the major retrenchment in domestic policy that the American right has been nominally dedicated to pursuing for most of the last century.

When Republican officeholders repeatedly shrink from risking the popular backlash that would naturally arise from large-scale implementation of their ideological commitments—note how the House GOP has acknowledged that simply repealing the ACA without replacement would invite electoral disaster—the unelected elements of the right respond by attacking them for betraying the Republican Party's conservative principles, threatening their defeat in primary elections and forcing them to make increasingly ambitious future promises that in turn are even more difficult to satisfy in practice. Regardless of where one's own sympathies might lie, observers across the political spectrum should be able to agree that this is not a fertile political environment for the prolific enactment of sound public policy.

About Me

I am a political scientist at Boston College who specializes in the study of American political parties, elections, Congress, and voting behavior. Email: david.hopkins {at} bc.edu. The name of this blog honors the notable political philosopher and practitioner George Washington Plunkitt.